Medical Device Integration Blog

For decades, complex systems have been a topic of study in natural sciences like physics, chemistry, mathematics, and engineering. The concept of complex systems has been used to explain phenomena such as immune system functions and weather patterns. Complex adaptive systems evolve in response to the changing environment; the need to adapt in order to survive. Tremendous progress has been made in applying Complex Adaptive Systems (CAS) modeling to other disciplines with a more social nature.

Healthcare is a CAS on many levels, from the daily interactions between patients and staff to the overarching interaction of healthcare systems. These systems have a natural tendency to adapt to change; to dynamic events that unfold in unpredictable and unique ways. Each individual component affects the other creating a chain of events.

I’d like to explore how these complex adaptive systems are important to clinical informatics.

Simply put, as new processes are introduced we, healthcare informaticists,need to review and study the potential outcome. We must always be aware that systems will adapt naturally to meet their needs.

It is well known that nurses are masters at procuring and creating workarounds in an effort to survive a change in workflow. Therefore, as we introduce new products, we must consider the concept of healthcare as a CAS and evaluate the potential adaptive behavior. For example, launching a new process or product in a pilot location my help to identify a potential negative work-around. The new process should then be evaluated and possibly adjusted to be sure that it is meeting the needs of the clinicians. As a vendor, having clinicians on staff with an awareness of CAS will promote the delivery of proven CAS methodology products.

What does your organization do to assure negative workarounds are not implemented with new products or processes?

Negative workarounds? Is there such a thing? Most workarounds I see are a matter of necessity because the damned app assumed it was omnipotent and didn't realize that reality is full of exceptions.
Name 1 negative workaround.

Michelle Grate, RN

@Paula, I appreciate your comment as it helps to open up dialogue around the topic of Complex Adaptive Systems. To expand or clarify my point further: with any new process or project, whether it is informatics related or not, those implementing the process/product need to work closely with clinicians to review the impact. As informaticists we should not assume a new process will be fully adopted by the clinicians. If the new process/product does not meet their needs and becomes a hindrance, they will look for workarounds in order to get the work done. These workarounds can have unintended negative consequences. I agree with you that reality is full of exceptions, therefore those exceptions need to be fully vetted during a pilot phase in order to be identified and reviewed. One example of a negative workaround is when users administer medication without scanning the patient ID to confirm the correct patient during a barcode medication administration process. This can result in medications delivered to the wrong patient. Informaticists need to address why this occurred. Was the wristband missing or damaged? Was the barcode scanner not working? What can be done to prevent this workaround from occurring in the future? There are other good examples in an article by Koppel, Wetterneck, Telles and Karsh, 2008: "Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety."
Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B. T. (2008). Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc, 15(4), 408-423. doi: 10.1197/jamia.M2616